Beechwood Homes

Based on observation, the facility did not equip corridors with firmly secured handrails on four (Units 4, 5, 7, 8) of eight resident units and one of one Second Floor Therapies area in the West Village. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings include but are not limited to:

1. Observations of Unit 8 revealed handrails were not securely attached as follows:

- On 3/1/10 at approximately 9:36 AM, an approximate three foot section of handrail was not securely attached to the corridor wall near resident room #841.
- On 3/1/10 at approximately 9:42 AM, an approximate four foot section of handrail was not securely attached to the corridor wall near resident room #838.
- On 3/1/10 at approximately 9:43 AM, an approximate one foot section of handrail was not securely attached to the corridor wall near resident room #839.
- On 3/1/10 at approximately 10:11 AM, an approximate two foot section of handrail was not securely attached to the corridor wall near resident room #814.

2. Observations of Unit 7 revealed handrails were not securely attached as follows:

- On 3/1/10 at approximately 10:42 AM, an approximate two foot section of handrail was not securely attached to the corridor wall near the Nurses Station.
- On 3/1/10 at approximately 11:07 AM, an approximate three foot section of handrail was not securely attached to the corridor wall near the Resident Lounge.

3. Observation of the West Village Second Floor Therapies area revealed an approximate six foot and an approximate three foot section of handrail were not firmly secured to the wall. These sections of handrail were located on the walls of the Therapies area, near the elevator.

415.29

Based on observation and staff interview, the facility did not maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of disease and infection. One of one West Village Clinic had issues involving paper towels that were stored under sink plumbing. Three (Units 1, 3, 8) of eight resident units had issues involving resident care items, plastic cups, and boxes of tissues that were stored on the floor. Two (Units 5, 7) of eight resident units had issues with hoppers that were installed in areas open to the corridor. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings include but are not limited to:

1. Observation of Unit 5 near resident room #573 on 3/1/10 at approximately 12:10 PM revealed a hopper (a receptacle used to dispose debris and/or waste by flushing) used to aid in the washing of soiled linen, was installed in the Soiled Linen/Clean Linen area that is open to the corridor. Interview with the Director of Environment and Plant Operations and the Assistant Director of Environment and Plant Operations on 3/4/10 at approximately 1:48 PM revealed the hoppers were not part of the original approved construction project. The original project called for stationary style sinks that were approximately two feet high by two feet long by two feet wide. During the interview, it was learned that the hoppers were an internal change order that was made by the facility.

2. Observation in the West Building on 3/1/10 at approximately 10:20 AM revealed an open cardboard box containing paper towels was stored under the sink plumbing in the Clinic. Interview with the Lead Mechanic at the time of the observation revealed the Dentist uses the clinic.

3. Observation of Unit 8 on 3/1/10 at approximately 2:36 PM revealed two cardboard boxes containing 1000 vinyl gloves and one cardboard box containing 100 underpads were stored on the floor of the Storage room located near resident room #843.

4. Observation of Unit 1 on 3/2/10 at approximately 2:49 PM revealed an open cardboard box containing approximately 20 sterile urine cups and tubes were stored on the floor of the Clean Utility room.

415.19(b)(2)
415.29(6)(i)

Based on observation, the facility did not store, prepare, distribute and serve food under sanitary conditions. Three (One West, Two West, Three West) of three dining rooms located in the East Village, one (West Village Kitchen) of two main kitchens and one (Unit Six Hansen House) of eight resident units were not maintained. Issues include food preparation area floors that are carpeted and are not smooth, durable, and non-absorbent; lack of hand-washing facilities in the food preparation area and the presence of drain flies. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings include but are not limited to:

1. Observation on 3/1/10 at approximately 10:34 AM revealed the food preparation area in the East Village Unit One West Dining Room floor is carpeted and not smooth, durable, and non-absorbent. Further observation revealed the closest hand-wash sink was approximately twenty-five feet away in a staff restroom. The staff restroom was located outside the Dining Room in the corridor and was not readily accessible to the food preparation area.

2. Observation on 3/1/10 at approximately 9:00 AM, in the presence of the Dietary Manager, revealed there were drain flies in several locations in the West Village Main Kitchen. Three drain flies were observed at the clean/sanitized pots and pans rack. Three drain flies were observed at the dry storage room door and approximately twelve additional drain flies were observed on the ceiling of the dry storage room. Several drain flies were observed at the trash can next to the handwashing sink and in the handwashing sink itself.

3. Observation on 3/1/10 at approximately 10:00 AM, in the presence of the Dietary Manager, revealed several (approximately five) drain flies flying in the West Village Unit Six Hansen House Kitchen area.

415.14(h)
14-1.143(a)
14-1.170
14-1.160

Based on record review and staff interview, the facility did not ensure that a resident who is fed by a gastrostomy tube receives the appropriate treatment and services to prevent metabolic abnormalities. One (Resident #17) of four residents reviewed for gastrostomy tube feedings had an issue involving the lack of clarification of an unclear physician's order for a tube feeding and a tube feeding not administered as ordered/planned to ensure adequate intake. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #17 has diagnoses which include dysphagia (difficulty swallowing), anemia and chronic kidney disease.

Review of a Physician's Order dated 12/1/09 revealed orders to provide 2 Cal HN (liquid nutritional supplement with high nitrogen), 1 liter via PEG (percutaneous endoscopic gastrostomy - feeding tube inserted into the stomach) tube at 80 cubic centimeters (cc)/hour x (times) 12 hours. Review of Physician's Orders dated 1/20/10 and 2/24/10 revealed the 2 Cal HN tube feeding was continued at the same infusion rate with an order for NPO (nothing by mouth).

Interview with the Diet Technician on 3/2/10 at 11:30 AM revealed that the resident's dietary need was determined to be one liter of 2 Cal HN per day and that the Physician's Order should read "one liter of 2 Cal HN daily until complete". The Diet Technician further stated that the resident's weight has been stable within a pound for 6 months.

Review of Medication Administration Records (MARs) for the period from 12/1/09 through 2/28/10 revealed the order for 2 Cal HN - 1 liter via the PEG tube at 80 cc/hour for 12 hours was documented as provided daily starting at 8:00 PM and "Off" at 8:00 AM.

Review of Enteral (via the intestinal tract) Feeding Records dated 12/9/09 through 2/26/10 and interview with the Registered Nurse (RN) Assistant Director of Nursing (DON) on 3/2/10 at 11:30 AM revealed the resident consistently received the following amounts of 2 Cal HN via the gastrostomy tube feeding:

- 240 cc on the 3:00 PM to 11:30 PM shift,
- 600 cc on the 11:00 PM to 7:30 AM shift,
- 80 cc on the 7:00 AM to 3:30 PM shift (totaling 920 cc daily).

During the interview on 3/2/10 at 11:30 AM, the RN ADON stated that she spoke with the night nurse who documented the tube feeding for the 11:00 PM to 7:00 AM shift. The night nurse explained that she starts the feeding at 11:30 PM and records the amount of 2 Cal HN infused from 11:30 PM to 7:00 AM, a volume of 600 cc.

Interview with the 7:00 AM to 3:30 PM shift Licensed Practical Nurse (LPN) on 3/2/10 at 11:30 AM, revealed that she stops the tube feeding daily at 8:00 AM and there are different volumes of feed formula remaining. The LPN explained that she then documents that 80 cc was administered on her shift.

Review of a facility policy entitled Enteral Tube Feedings dated 4/11/07 revealed that the Dietitian and/or Diet Technician will "confirm the tube feeding order written in the physician order sheet in the medical record".

Review of a facility policy entitled Enteral Nutrition effective date 3/14/07, revealed that nursing staff are to document Intake & Output and complete the "Enteral Feeding Flow sheet per order".

415.12(g)(2)

Based on observation and staff interview, the facility did not store controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse in separately locked, permanently affixed compartments. One (West Village Unit Six Hansen House) of six units observed for the storage of controlled substances had an issue involving Schedule II and IV controlled drugs that were left on an open counter and not stored in a double locked, permanently affixed compartment. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation of a utility area at the end of the hall in the Hansen House on 3/1/10 at approximately 9:30 AM revealed one nearly full 30 milliliter (ml) bottle of Lorazepam (antianxiety/ sedative medication) 2 milligrams per milliliter (mg/ml) and one nearly full 30 ml bottle of Morphine Sulfate (narcotic pain medication) 20 mg/ml were located on a counter underneath a double locked narcotic cabinet. The bottles of Lorazepam and Morphine were left unattended and there was no nursing staff in the immediate area at the time of the observation.

Interview with the Licensed Practical Nurse (LPN) Medication Nurse on 3/1/10 at 9:35 AM revealed she forgot to put the medications away after she counted narcotics earlier in the morning at the change of shift. The LPN stated she could not believe she had done that.

415.18(e)(1)(2)

Based on observation, record review and staff interview, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. One (Resident #12) of 30 residents reviewed for quality of care had issues involving the lack of identification of the type of a permanently implanted pacemaker, a lack of a plan to monitor the pacemaker to ensure proper function, and lack of ongoing monitoring of excoriated skin by a registered professional nurse to evaluate the effectiveness of a topical treatment. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #12 has diagnoses of cerebral vascular accident (CVA -stroke), sick sinus syndrome (heart dysfunction resulting in abnormal heart beat), and has a permanently implanted pacemaker. Review of a Minimum Data Set (MDS) dated 12/18/09 revealed the resident has severe cognitive impairment, impaired long and short term memory, rarely understands and is rarely understood.

a). Review of Interdisciplinary Physician Notes dated 3/25/09 through 1/20/10 revealed the resident has a cardiac pacemaker, sick sinus syndrome and an irregular heart rhythm. Additional review of the medical record including Interdisciplinary Physician and Nursing Notes, and Consultation Reports dated 3/25/09 to 3/1/10 revealed no documentation of the actual type of pacemaker device or that the pacemaker had undergone a diagnostic check to ensure proper function.

Review of the Comprehensive Care Plan (CCP) dated 3/3/10 revealed no documentation that the resident has a pacemaker and there were no approaches related to pacemaker checks.

Interview with the Physician on 3/2/10 at approximately 3:00 PM revealed the resident should have pacemaker checks and did not have any because the pacemaker was working and was not the resident's main problem. Further interview revealed the resident is on "comfort care" (conservative, supportive measures provided at the end of life) and the Physician did not know what the family's wishes were regarding care of the resident's pacemaker.

b). Review of a Physician's Order dated 1/17/10 revealed a treatment order to cleanse "bilateral breast redness, excoriated areas" with wound cleanser and apply medicated powder BID (twice a day) until clear.

Review of Medication Administration Records (MARs) dated 1/17/10 to 3/2/10 revealed documentation that the treatment was provided BID as ordered since the Physician's Order on 1/17/10.

Observation on 3/2/10 at approximately 10:40 AM revealed two certified nurse aides (CNAs) provided morning care to Resident #12. CNA #1 washed underneath each of the resident's breasts. The skin below each of the breasts was moist, excoriated and grayish, red in color. After washing, each of the breast was observed to have a caked, whitish powder residue below it. The CNA patted the area dry and dressed the resident.

Interview with the Licensed Practical Nurse (LPN) Treatment Nurse on 3/2/10 at approximately 2:30 PM revealed she had provided the medicated powder treatment to the resident's breast area prior to morning care provided by the CNAs. The LPN stated that the CNAs did not report any problems with the resident's skin. The LPN further stated that she performs weekly skin checks on the residents during bath day and notes only new problems on the skin sheets. The LPN was aware that the resident had a skin problem with her breasts which was not improving and stated that the physicians had prescribed a treatment for the problem.

Interview with the LPN Unit Manager (UM), in the presence of the Physician, on 3/2/10 at approximately 2:45 PM revealed weekly skin rounds for pressure sores are done by herself and a Registered Nurse (RN). The LPN UM stated she believed the weekly skin checks done by the LPN on bath day and the daily reporting by the CNAs was adequate monitoring of the resident's skin under the breasts and she was confident that the CNAs would report any problems. During the interview, it was learned there was no documentation to show that an RN had regularly assessed the excoriated areas under the resident's breasts.

During an interview with the Physician, in the presence of the LPN UM, on 3/2/10 at approximately 3:00 PM, the Physician stated she recalled looking at the resident's skin in 1/10 and thought that leakage of gastric (stomach) contents from the resident's gastrostomy (feeding tube inserted into the stomach) tube caused the irritation under the breasts. Interview with the Physician on 3/2/10 at approximately 3:15 PM revealed she assessed the resident's skin, stated the area looked fungal and smelled, and indicated a plan to change the treatment.

Review of Physician's Orders dated 3/2/10 revealed orders to discontinue the medicated powder, and wash under the breasts with soap and water BID and apply Mycolog cream (antifungal, anti -inflammatory cream).

415.12

Based on observation, record review and staff interview, the facility did not ensure that a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. One (Resident #7) of 16 residents observed with positioning devices did not have bilateral hand rolls in place as planned per therapy recommendations. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #7 has diagnoses which include Alzheimer's disease, stroke, and expressive aphasia (absence or difficulty with speech). Review of the Minimum Data Set (MDS) dated 2/19/10 revealed the resident has severely impaired cognition, rarely/never understands others, is rarely/never understood, and has short and long term memory problems. The MDS documented the resident requires total care with daily care needs such as transfers, dressing, eating, and hygiene/bathing. Review of the Care Plan (comprehensive care plan) dated 2/24/10 revealed an approach for "bilateral hand rolls after AM care with elastic hand straps. May use washcloth rolls".

Review of an Occupational Therapy (OT) note dated 3/24/09 revealed the resident was issued bilateral hand rolls due to a tendency to keep her fingers flexed. The Occupational Therapist documented that the hand rolls should be applied after morning care and be used throughout the day as tolerated. An Occupational Therapy note dated 5/17/09 documented that OT provided a hand cone to the resident to "prevent further deformation". An OT note dated 6/15/09 documented the bilateral hand rolls were reissued.

Review of a CNA (certified nurse aide) Assignment Sheet dated 2/26/10 revealed the plan for hand rolls to both hands after morning care with elastic straps or washcloth rolls can be used.

Intermittent observations on 3/2/10 from 8:30 AM to 3:00 PM and 3/3/10 from 8:00 AM to 12:00 PM revealed the resident did not have the hand rolls or washcloth rolls in place. During an interview on 3/3/10 at 12:10 PM, the CNA who was assigned to the resident, stated one of the hand rolls had been missing for at least one week, so she did not use the other hand roll. The CNA stated she had told a nurse about the missing hand roll. When questioned about the use of washcloths instead of the hand rolls, the CNA said she did not know she could use washcloths. During an interview on 3/3/10 at 12:15 PM, the Registered Nurse (RN) Acting Unit Manager stated she was unaware that a hand roll was missing.

Interview with the Director of Rehabilitation and Occupational Therapy on 3/4/10 at 8:45 AM revealed the resident has contractures of both shoulders, both elbows and both knees. The Director stated hand rolls are used to prevent hygiene problems, protect the skin and to prevent contractures. A Physical Therapy Annual Assessment dated 11/4/09, reviewed with the Director during the interview, documented "declines are expected as res (resident) is non ambulatory and does not voluntarily move extremities".

415.12(e)(2)

Based on observation, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Six (Units 1, 2, 3, 5, 6, 7) of eight resident units had issues involving mechanical lifts that were soiled and/or had torn arm rests. This was a pattern with no actual harm with potential for minimal harm.

The findings include but are not limited to:

1. Observation of the Unit 3 corridor on 3/4/10 at approximately 10:37 AM revealed the foot plate of a mechanical sit to stand lift, located near resident room #303, was soiled with food debris, crumbs, dust and pieces of plastic. Further observation at this time revealed there was a two inch by two inch area of the foam cover, on both the left and right arm rests, that was soiled with a white substance.

2. Observation of the Unit 2 corridor on 3/4/10 at approximately 10:42 AM revealed the foot plate of a mechanical sit to stand lift located near resident room #201 was soiled with food debris; brown and yellow substances; dust; and pieces of cotton. Further observation at this time revealed there was a two inch tear in the foam padding covering both the left and right arm rests.

3. Observation of the Unit 7 corridor on 3/4/10 at approximately 10:45 AM revealed the foot plate of a mechanical sit to stand lift, located near resident room #762, was soiled with food debris, brown and yellow substances, and dust. Further observation at this time, revealed there was a five inch tear in the foam padding on both the left and right arm rests.

415.5(h)(2)
415.29(j)(1)

Based on observation during a Life Safety Code survey, one of one fire barrier wall between the East Village building and The Commons corridor was not complete from floor to roof deck. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation above the ceiling tiles on 3/2/10 at approximately 2:30 PM revealed an approximate two foot by ten inch and an approximate one foot by four inch penetration in the block fire barrier wall that separates the East Village building from The Commons corridor. These penetrations were located above the fire barrier doors that separate the East Village Building from The Commons corridor.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
1997 NFPA 101: 13-1.1.4, 13-1.1.4.1, 13-1.1.4.2, 6-2, 6-2.1
2000 NFPA 101: 19.1.1.4, 19.1.1.4.1, 19.1.1.4.2, 8.2, 8.2.1(1)

Based on observation during a Life Safety Code survey, corridor walls in one (Eastview) of two basements of the West Village were not complete from floor to roof deck and/or would not resist the passage of smoke. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation in the Eastview Basement on 3/1/10 at approximately 4:10 PM revealed an approximate two inch open unsealed penetration in the corridor wall of the Air Conditioning Storage room. This penetration was located above the door of the Air Conditioning Storage room and would not resist the passage of smoke.

2. Observation in the Eastview Basement on 3/1/10 at approximately 4:12 PM revealed an approximate one half inch open unsealed penetration around an approximate four inch pipe in the corridor wall of the Activities Storage room. This penetration was located next to the door of the Activities Storage room and would not resist the passage of smoke.

3. Observation in the Eastview Basement on 3/4/10 at approximately 9:00 AM revealed an approximate two foot by one inch open unsealed penetration between a ventilation duct and the corridor wall of the Mechanical room. This penetration was located near the single door to the Mechanical room and would not resist the passage of smoke.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
1997 NFPA 101: 13-3.6.1, 13-3.6.2.1
2000 NFPA 101: 19.3.6.2, 19.3.6.2.1

Based on observation during a Life Safety Code survey, fire/smoke barrier doors on two (Units 4, 5) of eight resident units had gaps between them that were greater than one quarter of an inch when they were closed and thus would not resist the passage of smoke. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on 3/1/10 at 11:36 AM revealed the Fire/Smoke Barrier doors located between Unit 5 and The Commons were hung up on each other revealing an approximate two inch gap between the top of the right door and the door's frame. This is the right door as you view the doors from Unit 5 looking into The Commons corridor.

2. Observation on 3/1/10 at approximately 11:46 AM revealed the gap between the Unit 5 smoke barrier doors located near resident room #513 was greater that one quarter of an inch when the doors were closed.

3. Observation on 3/1/10 at approximately 11:58 AM revealed the gap between the Unit 5 smoke barrier doors located near resident room #561 was greater that one quarter of an inch when the doors were closed.

4. Observation on 3/1/10 at approximately 2:27 PM revealed the gap between the Unit 4 smoke barrier doors located near resident room #432 was greater that one quarter of an inch when the doors were closed.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
1997 NFPA 101: 13-3.7.6, 6-3.4, 6-3.4.1
2000 NFPA 101: 19.3.7.6, 8.3.4, 8.3.4.1

Based on observation during a Life Safety Code survey, clearance was not maintained in front of electrical panel boxes on four (Units 4, 5, 7, 8) of eight resident units. Issues included electrical panel boxes that had various items stored less than 36 inches from them. Items included but are not limited to the following: a refrigerator, coffee maker, three foot tall basketball style hoop, laundry basket, coats, boots, and bags that were stored less than 36 inches from electrical panel boxes. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings include but are not limited to:

1. Observation on Unit 8 on 3/1/10 at approximately 10:01 AM revealed a three foot tall refrigerator, a coffee maker, a three foot tall basket ball style hoop, a laundry basket, coats, boots and bags were stored directly in front of three electrical panel boxes located in the Conference/Living room.

2. Observation on Unit 7 on 3/1/10 at approximately 11:13 AM revealed an approximate three foot tall metal rack full of cleaning supplies and an approximate three foot long by three foot tall by two foot wide mobile linen tote were stored directly in front of two electrical panel boxes in the Storage room located near the Clean Linen and Soiled Linen area.

3. Observation on Unit 5 on 3/1/10 at approximately 12:05 PM revealed approximately three foot long by three foot tall by two foot wide mobile linen tote, a trash receptacle and a recycle bin were stored directly in front of two electrical panel boxes in the Storage room located near the Clean Linen and Soiled Linen area.

4. Observation on Unit 4 on 3/1/10 at approximately 2:19 PM revealed a housekeeping cart and a vacuum were stored directly in front of an electrical panel box located in the Housekeeping Closet located near the Wesley Dining room.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
none 1997 NFPA 101: 7-1.2
2000 NFPA 101: 9.1.2
1999 NFPA 70: Article 110-26

Based on observation and staff interview during a Life Safety Code survey, monthly testing and a written record of the testing of firefighters service phase I and phase II is not being conducted on two of two elevators located in the East Village Building and three of three elevators located in the West Village Building. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Intermittent observations on 3/1/10 and 3/2/10 between the hours of 11:15 AM and 3:09 PM revealed that elevators 1 and 2 located in the East Village Building and elevators A, B, and the Receiving Elevator located in the West Village Building were equipped with firefighters service phase I and phase II. Interview with a member of the maintenance staff on 3/2/10 at approximately 3:10 PM revealed that fire fighter service phase I and phase II for all of the facility's elevators was tested once a year and that the facility did not keep a written record of the test.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
none 1997 NFPA 101: 13-3.5.3, 7-4, 7-4.8
2000 NFPA 101: 19.5.3, 9.4, 9.4.6
ASME/ANSI A17.1 Safety Code for Elevators and Escalators

Based on observation during a Life Safety Code survey, corridor mounted computer touch screens were not properly installed on four (Units 3, 4, 5, 7) of eight resident units. Issues included corridor mounted computer touch screens that projected greater than three and one half inches into the corridor and were mounted less than approximately 60 inches from the floor. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on 3/3/10 at approximately 9:14 AM on Unit 5 revealed a corridor mounted computer touch screen projected approximately four and one quarter inches into the corridor and was mounted approximately 52 and one half inches from the floor near resident room #570. Observation in the Unit 5 corridor on 3/4/10 at approximately 9:07 AM revealed the corridor is approximately seven feet wide near resident room #570.

2. Observation on 3/3/10 at approximately 9:23 AM on Unit 7 revealed a corridor mounted computer touch screen projected approximately four and one quarter inches into the corridor and was mounted approximately 52 and one half inches from the floor near resident room 763. Observation in the Unit 7 corridor on 3/4/10 at approximately 9:10 AM revealed the corridor is approximately seven feet wide near resident room #763.

3. Observation on 3/3/10 at approximately 9:31 AM on Unit 4 revealed a corridor mounted computer touch screen projected approximately four and one quarter inches into the corridor and was mounted approximately 52 and one half inches from the floor near resident room 461. Observation in the Unit 4 corridor on 3/4/10 at approximately 9:15 AM revealed the corridor is approximately seven feet wide near resident room #461.

4. Observation on 3/3/10 at approximately 9:37 AM on Unit 3 revealed a corridor mounted computer touch screen projected approximately four and one quarter inches into the corridor and was mounted approximately 52 and one half inches from the floor near resident room 307. Observation in the Unit 3 corridor on 3/4/10 at approximately 9:30 AM revealed the corridor is approximately eight feet wide near resident room #307.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
1997 NFPA 101: 5-3.2, 13-2.3.1, 13-2.3.3
2000 NFPA 101: 7.3.2, 19.2.3.1, 19.2.3.3

Based on observation during a Life Safety Code survey, two (Eastview, Main) of two Basement corridors in the West Village were not continuously maintained free of all obstructions or impediments to full instant use in case of a fire or other emergency. One (North) of two stairways from the West Village Main Basement and two of five exit egresses from The Commons (the corridor that connects the East Village to the West Village) were obstructed by leaves, a high-backed rocking chair and/or ice and snow. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings include but are not limited to:

1. Observation in the West Village on 3/1/10 at approximately 4:21 PM revealed the following were stored in the Eastview Basement corridor:

- 25 upholstered chairs,
- 8 end tables,
- 6 high-backed oversized upholstered chairs,
- 2 upholstered Love seats,
- 2 five foot tall by four foot long by three foot high armoires,
- 2 wheelchairs,
- 2 three wheeled electric scooters,
- 1 five foot long by two foot wide by three foot high desk,
- 1 folding table,
- 1 five foot tall by four foot long by two foot wide mobile tub chair,
- 1 four foot long by three foot wide by three foot tall Therapy table
- 1 five foot long by three foot wide by three foot tall dresser.

2. Observation on 3/1/10 in the West Village at approximately 4:26 PM revealed the following was stored in the Main Basement corridor:

- 7 upholstered chairs,
- 1 approximately 55 gallon trash receptacle that was partially full of what appeared to be bed sheets,
- 1 approximately 20 gallon trash receptacle with a shovel in it,
- 1 wooden door,
- 1 four foot long by three foot wide by three foot tall mobile tote,
- 1 five foot long by four foot wide by three foot tall mobile linen tote,
- 3 six foot tall by four long by two foot wide soiled line receptacles that were full of soiled linen.

3. Observation on 3/1/10 at approximately 4:30 PM revealed the first seven steps of the North stairway that leads from the West Village Main Basement to the exterior of the building were covered with dry and wet leaves ranging in thickness from approximately four to eight inches.

4. Observations in The Commons on 3/1/10 at approximately 2:45 PM and on 3/2/10 at approximately 10:00 AM revealed that ice and snow ranging in thickness from two to six inches was obstructing an approximately 60 feet section of the blacktop path that leads from the exit door located closest to Unit 5 of the West Village building to the East Village Building Parking lot.

5. Observations in The Commons on 3/1/10 at approximately 2:46 PM and on 3/3/10 at approximately 9:34 AM revealed a rocking chair was stored directly in front of one of the two exit doors located near the Education Center Classroom/Staff Development room. The exit door that was obstructed by the rocking chair was the door that is located closest to the East Village building.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
1997 NFPA 101: 5-1.9, 5-1.9.1
2000 NFPA 101: 7.1.10, 7.1.10.1

Based on record review and staff interview during a Life Safety Code survey, required annual inspections and maintenance had not been performed within one year on portable fire extinguishers located on two (Units 4, 8) of eight resident units and one of one East Village Main Kitchen, one of one West Village Main Kitchen and two (Eastview, Main) two Basements of the West Village. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings include but are not limited to:

1. Record review of the tag attached to the K-type portable fire extinguisher located near in the West Village Main Kitchen on 3/1/10 at approximately 9:20 AM revealed that the extinguisher's annual inspection and maintenance was due in 1/10. The last annual inspection was conducted in 1/09.

2. Record review of the tag attached to the portable fire extinguisher located near resident room #839 on Unit 8 on 3/1/10 at approximately 9:41 AM revealed that the extinguisher's annual inspection and maintenance was due in 1/10. The last annual inspection was conducted in 1/09.

3. Record review of the tag attached to the portable fire extinguisher located in the Unit 8 Horizons Household Kitchen on 3/1/10 at approximately 9:50 AM revealed that the extinguisher's annual inspection and maintenance was due in 1/10. The last annual inspection was conducted in 1/09.

4. Record review of the tag attached to the K type portable fire extinguisher located in the East Village Main Kitchen at approximately 10:40 AM revealed that the extinguisher's annual inspection and maintenance was due in 1/10. The last annual inspection was conducted in 1/09.

5. Record review of the tag attached to the portable fire extinguisher located near resident room in the Wesley Dining room on Unit 4 on 3/1/10 at approximately 2:14 PM revealed that the extinguisher's annual inspection and maintenance was due in 1/10. The last annual inspection was conducted in 1/09.

6. Record review of the tag attached to the portable fire extinguisher located in the West Village Eastview Basement corridor on 3/1/10 at approximately 4:10 PM revealed that the extinguisher's annual inspection and maintenance was due in 1/10. The last annual inspection was conducted in 1/09.

7. Record review of the tag attached to the portable fire extinguisher located in the West Village Main Basement corridor on 3/1/10 at approximately 4:37 PM revealed that the extinguisher's annual inspection and maintenance was due in 1/10. The last annual inspection was conducted in 1/09.

Interview with a member of the Maintenance staff on 3/4/10 at approximately 8:51 AM revealed the outside vendor that performs annual inspections and maintenance on the facility's portable fire extinguishers started their annual inspection/maintenance of the facility's portable fire extinguishers in 1/10 but that they did not return until 3/2/10 to replace all of the portable fire extinguisher that needed annual inspections and maintenance.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
1997 NFPA 101: 13-3.5.6, 7-7.4.1
2000 NFPA 101: 19.3.5.6, 9.7.4.1
1998 NFPA 10: 4-1.2, 4-4, 4-4.1

Based on observation during a Life Safety Code survey, smoke barriers on one (Unit 3) of three resident units of the East Village were not complete from floor to roof deck. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation above the ceiling tiles in the Unit 3 Bathing Suite Toilet room on 3/2/10 at approximately 1:41 PM revealed the following penetrations in the Unit 3 smoke barrier wall:

a). One, approximately one inch by one half inch open, unsealed penetration between two pieces of gypsum board.
b). One, approximately four foot long open, unsealed penetration between a piece of gypsum board and a protected steel beam that ranged from one quarter inch to one half inch in width.
c). One, approximately three inch by one half inch open, unsealed penetration in a piece of gypsum board.
d). One, approximately two inch by one inch open, unsealed penetration in a piece of gypsum board.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
1997 NFPA 101: 13-3.7.3, 6-3.2
2000 NFPA 101: 19.3.7.3, 8.3.2

Based on observation, record review and staff interview during a Life Safety Code survey, sprinkler inspections were not conducted on a quarterly basis on eight (Units 1, 2, 3, 4, 5, 6, 7, 8) of eight resident units and sprinkler piping in one (First Floor) of one Maintenance Shop in the East Village building had wiring zip tied to it. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on the First Floor of the East Village on 3/1/10 at approximately 4:04 PM revealed that bundles of electrical wiring and data/computer wiring were zip tied to approximately 20 feet of a sprinkler pipe located in the Maintenance Shop.

2. Record review on 3/2/10 at approximately 10:30 AM and 3/3/10 at approximately 3:38 PM revealed the facility's automatic sprinkler systems located in the East Village (Units 1, 2, 3) were inspected and tested on 2/5/09, 7/24/09 and 10/22/09. Record review on 3/2/10 at approximately 10:30 AM and on 3/3/10 at approximately 3:38 PM revealed the facility's automatic sprinkler systems located in the West Village (Units 4, 5, 6, 7, 8) were inspected and tested on 2/5/09, 7/23/09 and 10/22/09.

Interview with a member of the Maintenance staff on 3/2/10 at approximately 3:20 PM revealed the outside vendor that inspects and tests the facility's automatic sprinkler system came later in the year than they were suppose to and therefore the system was not inspected and tested on a quarterly basis.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
1997 NFPA 101: 7-7.5
2000 NFPA 101: 9.75, 19.7.6, 4.6.12
1998 NFPA 25: 2-1, 2-2.2
1999 NFPA 13: 6-1.1.5

Based on observation and staff interview during a Life Safety Code survey, vertical openings between floors were not properly protected. Issues included open, unsealed penetrations in one of one observed elevator shaft in the East Village Building and one (Receiving Dock) of one observed elevator shaft in the West Village Building as well as open unsealed conduits between two (Units 1, 2) of three resident units of the East Village. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation above the ceiling tiles in the East Village Building First Floor Elevator Lobby on 3/2/10 at approximately 2:25 PM revealed an approximate two inch by two inch open, unsealed penetration into the Elevator Shaft for Elevators 1 and 2.

2. Observation in the attic of the West Village Building on 3/2/10 at approximately 3:03 PM revealed an approximate eight inch by six inch open, unsealed penetration and an approximate one half inch open unsealed penetration around a two inch pipe in the Receiving Dock elevator shaft.

3. Observation in the East Village Building on 3/2/10 at approximately 3:25 PM revealed two approximately two inch open unsealed conduits were protruding through the floor of the Unit 2 Clean Utility room. This room is located near the Unit Mangers office. Observation above the ceiling tiles in the East Village Building on 3/2/10 at approximately 2:48 PM revealed two approximately two inch open, unsealed conduits were protruding through the ceiling of the Unit 1 Clean Utility room. Interview with a member of the maintenance staff at this time confirmed that the Unit 2 Clean Utility room is located directly above the Unit 1 Clean Utility room and that the conduits are open and unsealed between the first and second floors.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
1997 NFPA 101: 13-1.1, 6-2.4, 6-2.4.1, 6-2.4.2
2000 NFPA 101: 19.3.1.1, 8.2.5, 8.2.5.1, 8.2.5.2